UNIQUE NEEDS OF CHILDREN DURING DISASTERS AND OTHER PUBLIC HEALTH

EMERGENCIES

Physiologic Considerations in Pediatric Care

A. Pulmonary System
 Children have faster Respiratory Rate, higher metabolic rate as well as greater
minute ventilation increase their risk of inhaling a higher dosage or amount of
toxic airborne substances including radioactive gases.
 Oxygen consumption in infants is 6 to 8 mL/kg/minute compared to 3 to 4
mL/kg/min in adults hence they may require early oxygen administration
following exposure to noxious chemicals.
 Tachypnea—nonspecific sign of respiratory distress observed in pediatrics
exposed to toxic gases
 Infants and young children have cartilaginous and thus compliant chest walls.
This anatomical fugure has both medical and trauma implications. When a child
is in respiratory distress, substernal, supraclavicular, infraclavicular, intercostal or
substernal retractions result from the child’s increased work of breathing.
B. Cardiovascular
 Child’s estimate blood volume is 80 mL/kg, which is larger than adult on a
millimeter per kilogram basis and this can result in small amount of blood loss
from trauma decreasing circulating blood volume leading to shock.
 Children have greater cardiac reserves than adult allowing to compensate for
fluid losses from hemorrhage, diarrhea, or lack of oral intake. However, when
this fails, shock and cardiopulmonary failure results quickly. (severe trauma,
burn, biological/chemical trauma)
 Tachycardia- non specific sign of cardiopulmonary distress
 Delayed capillary refill time- important indicator of cardiopulmonary compromise
during early stage of shock
 In compensated shock- children’s vital sign will remain within their age range or
slightly elevated.
 Hypotension is not observed until the child lost 20%-25% of his or her circulating
blood volume and is a sign of decompensated shock.
 Fluid replacement mjust be done quick and aggressively to prevent shock.
C. Integumentary
 They have thinner and more permeable skin than adults, hence they have
greater exposure to and absorption of dermal toxicants.
 They have less subcutaneous fats than adult.
 They have higher body area-to-weight ratio predisposing them to greater heat
loss through conduction, convection, radiation and evaporation.
 They have higher risk for hypothermia because of an immature thermoregulatory
system and higher surface area-to mass ration.
 Infants less than 6 months old do not have fine motor coordination to shiver and
are unable to keep themselves warm; nonshivering thermogenesis occurs where
brown fat is broken down to produce warmth.
  Access to heating sources such as heat lamps, blankets, and intravenous fluid
warmers will be needed to prevent hypothermia in pediatric population.
D. Musculoskeletal
 Physical injury to yhe growth plate may lead to growth arrest or deformity.
 Young bpnes are compliant, therefor affording less protection to underlying body
organs (lungs, heart, liver, brain) when external forces are applied. This may
lead to significant internal injuries.
 Along with large size of organs among children, their proximity in the abdominal
compartment and injured to several organs can occur from a single penetrating
or blunt force.
E. Cognitive
 Young children are unlikely to recognize danger or to protect themselves from it.
 The confusion and disruption present during a disaster may cause extreme levels
of fear and anxiety in children and may be magnified when they see their
parents experiencing the same levels of fear.
F. Nutritional Requirements
 Children have a greater growth rate and subsequent higher protein and calorie
requirements when compared with adults.
 Protein-energy malnutrition may occur in complex emergency where there is
inadequate food source.
 Protein-energy malnutrition—marasmus, kwashiorkor, marasmic-kwashiorkor.
 Diagnosed when child’s arm circumferenc is less than the 5 th percentile or less
than 80% of the reference standard.
 They have greater risk to secondary infections and complications leading to
death.
G. Immunologic
 They are susceptible to infection due to their undeveloped immune system.
 Sepsis may be encountered in children and infants exposed to biologic agents.
 The thyroid gland is also sensitive to the carcinogenic effects of radiation
exposure.

Pediatric Disaster Triage

 A higher proportion of children involved in disaster would occur if the event included
predominantly pediatric setting (e.g. school, school bus, children’s hospitaljuvenile
detention center)
 Pediatric equipment, supplies and medications must be brought by the Rescue officers.
 JumpStart Pediatric Multiple Casualty Incident Triage
 Method used in mass casualty incidents and is modeled after the Simple Triage
and Rapid Treatment (START)
 It assesses the victim’s airway, vital signs and level of consciousness
categiorizing them in: Minor, delayed, immediate, deceased
 It is designed to be completed in 60 seconds.
 SAVE- Secondary Assessment of Victim Endpoint
  Developed to direct limited resources to the subgroup of patients expected to
derive the most benefit from their application.
 It assesses survivability in relation to injuries and, on the basis of trauma
statistics, applies this information to describe the relationship between expected
benefits and consumed resources.
 SMART Triage Tape- incorporates a JumpSTART-like triage approach using a
color coded length-based tape that is designed to provide the responders with a
rapid understanding of what physiological signs and symptoms should be
considered.
 SALT- Sort Assess Life-Saving Intervensions Treatment and Transport.
 Inclusive of both adults and children
 Not yet universally accepted despite being endorsed by CDC.
 TRAIN- Triage by Resource Allocation for IN-patient
 Hospital triage system designed as a proactive assessment of patients in the
hospital either by building proactive assessment if patients in the hospital either
by building the tool in to the hospital electronic records or a quick paper-based
assessment based on the utilization of equipment, medication, and respiratory
and medical support.
 It uses simple scoring scale that evaluates the patient’s transportation needs
based on the following criteria: transportation option, life support, mobility,
nutrition and pharmacy.
 PsySTART triage—Developed by Sr. Merritt Shreiber
 A mental health triage system to assist with the identification of children and
adults who are at the greatest risk for adverse outcomes.
 It uses individual’s self-report using a checklist scoring system

Primary Survey of the Pediatric Trauma Patients

Component Actions
Airway/ cervical spine  Assess for airway patency – check for loose teeth, vomitus or
other obstructions
 Suspect cervical spine injury with multiple trauma—maintain
neutral alignment during assessment. Evaluate effectiveness
of cervical immobilization and other equipment used to
immobilize spine
 THE USE OF RIGID C-COLLARS IS NOW CONSIDERED A
POTENTIAL DANGEROUS PRACTICE. EVP NOW
ENCOURAGES SPINAL STABILIZATION WITHOUT USE OF
RIGID BACKBOARDS OR RIGID COLLARS.
Breathing  Auscultate breath sounds in the axillae and throughout the
chest area for presence and equality.
 Assess for chest contusions, penetrating wounds, abrasions,
or paradoxical movements.

Circulation  Assess apical pulse for rate, rhythm and quality; compare
apical pulse with peripheral pulse for equality and quality.
  Evaluate capillary refill
 Check for skin color and temperature
 Note for open wounds and uncontrolled bleeding;applyu
direct pressure or torniquet as necessary.
Disability (neurologic)  Assess for level of consciousness and orientation to person
and place, and time for older children
 In younger child, assess for alertness, ability to interact with
environment, and ability to follow commands.
 Check pupils for reactivity, size and equality
Expose  Remove clothing to allow visual inspection of the body.

Secondary Survey of the Pediatric Trauma Patients

Component Actions
Head, eye, ear and  Assess scalp for lacerations or open wounds; palpate for step-
nose off defects, depressions, hematomas, and pain
 Reassess pupil for size, equality and reactivity, and extraocular
movements; ask child if he or she can see
 Assess ears and nose for rhinorrhea or otorrhea
 Observe for raccoon eyes (bruising around the eyes); or Battle’s
sign (bruising over the mastoid process)
 Palpate forehead, orbits maxilla, and mandible for crepitus,
deformities, step-off defects, pain and stability, evaluate
malocclusion by asking child to open and close mouth; note for
open wounds.
 Inspect for loose, broken or chipped teeth as well as oral
lacerations.
 Check orthodontic appliances for stability
 Evaluate facial symmetry by asking child to smile, grimace, and
open and close mouth.
 Do not remove impaled objects or foreign objects.

Neck  Open cervical collar and reassess anterior neck for jugular vein
distention and tracheal deviation; note for bruising, edema,
open wounds, pain and crepitus.
 Check for hoarseness or changes in voice by asking child to
speak.
Chest  Obtain respiratory rate, breath sounds in anterior lobes for
equality. Palpate chest wall and sternum for pain, tenderness
and crepitus.
 Observe inspiration and expiration for symmetry or paradoxic
movement; note use of accessory muscles.
 Reassess apical heart rate, rhythm and clarity
Abdomen, pelvis,  Observe abdomen for bruising and distention; auscultate bowel
genitourinary sounds briefly in all four quadrants; palpate abdomen gently for
tenderness; assess pelvis for tenderness and stability.
 Palpate bladder for distention and tenderness; check urinary
meatus for signs of injury or bleeding; not priapism and genital
 trauma such as lacerations or foreign body
 Have rectal sphincter tone assessed usually by physicians.
Musculoskeletal  Assess extremities for deformities, swelling, lacerations or other
injuries. Palpate distal pulse for equality, rate, rhythm, and
compare to central pulse.
 Ask child to wiggle toes and fingers; evaluate strength through
hand grips and foot flexion and extension.
Back  Logroll as a unit to inspect the back; maintain spinal alignment
during examination; observe for bruising and open wounds;
palpate each vertebral body for tenderness, pain, deformity and
stability; assess flank area for bruising and tenderness.

Pediatric Care during Public Health Emergencies

A. Exposure to Nuclear and Radiologic Agents

 Prehospital Treatment
 Dose rate meters—devise that can detect radioactive contamination
 Pediatric advance life support always take precedence over radiation issues. It is
better to have dirty patient who is alive than to have a dead clean patient.
 Removal of contaminated clothing results in the elimination of 90% of the
contamination.
 PPE’s must be worn by health care providers in entering a highly contaminated
area. Respirators must be worn.
 Surface decontamination can be undertaken in the absence of physical injuries;
in the presence of life-threatening injuries, such injuries are stabilize prior to
decontamination.
 Separate facilities for decontamination must be available for male and female.
 Young children and infants should remain to their parents or caregivers, while
older children can be decontaminated in a designated area based on their
gender.
 Contaminated items are placed in labeled plastic bags and properly disposed or
held for law enforcement purposes.
 Open wounds should be covered until decontamination is completed.
 Emergency Department Treatment
 Before the patient arrive at the ER, area for decontamination and treatment
should be prepared to prevent spread of contamination.
 Triage should include radiological survey to assess the dose rate, documentation
of prodromal symptoms and collection of tissue sample for biodosimetry.
 Children should be given age- appropriate explanation of what is happening to
them and what they will feel.
 Definitive Treatment
1. Should children be exposed to the detonation of a nuclear weapon or the
release of radioactive material from a nuclear reactor and iodine is a
byproduct of the release, potassium iodide (KI) or iodate would be
administered to prevent radioiodine from accumulating in the thyroid gland.
 KI should be administered immediately or at least within 8 hours
postexposure
2. KI should be administered with caution in children and adolescents with a
known or reported allergy to iodide, as severe allergic reactions have been
reported
3. In newborns, KI administration has been linked with transient decreases in
thyroxine along with increases in thyroid-stimulating hormone (AAP, 2003).
Therefore, newborns who receive KI should have ongoing monitoring of their
thyroid function by measuring thyroid- stimulating hormone activity 2 to 4
weeks postadministration of a single KI dose or for longer periods than when
one KI dose is administered.
4. Because both radioiodine and KI are secreted into human breast milk,
lactating women who receive KI should not breastfeed their infants because
of the risk of additional exposure to radioiodine from breast milk.
5. Public health officials will determine when it is safe to resume breastfeeding
and when it is safe to consume produce and milk following a radiological
exposure.
6. KI is prepared in tablets, making it easier to store. Infants and children may
not be able to swallow tablets, When dissolved in water, the fluid is too salty
to drink. To disguise the salty taste of the K1, the tablet can be crushed and
mixed with raspberry syrup, low-fat chocolate milk, orange juice, or flat soda.
7. Crush one 130-ms KI. tablets into small pieces; add four teaspoons of water
to the crushed tablet to dissolve it; then aad four teaspoons of one of the
aforementioned fluids to the mixture making 130 mg per four teaspoons of
solution.
8. The recommended daily dose for Kl in children 4 to 18 years of age is four
teaspoonfuls: for children 1 month through 3 years of age, two teaspoonfuls;
and for newborns and infants less than I month of age, one teaspoonful; 18
years of age weighing 150 or more pounds. eight teaspoons.
9. This daily dosing should continue until the risk of exposure has passed or
until other measures, such as evacuation, sheltering, and control of the food
and milk supply, have been implemented successfully.
10. For children exposed to cesium-137 and thallium, Prussian blue is
administered. Prussian blue enhances the excretion of these agents in the
stool, thereby decreasing radiation exposure
11. The dosage for Prussian blue is 3 to 10 g/d by mouth (0.21-0.32 g/kg/d)
12. Following exposure to plutonium, curium and americium chelation with
pentetate calcium trisodium (CaDTPA), pentetale zinc trisodium (Zn-DTPA),
or dimercapto propane-1-sulfonit acid (MIPS) can be administered
13. Ca-DTPA and Zn-DTPA chelate with metals and are excreted in the urine.
These medications are administered by inhalation or intravenous routes at a
dosage of 14 mg/kg IV, up to a maximum of 1 g.
14. Children are one of the groups at high risk of psychological effects following
terrorist attacks and subsequent exposure to radiation. Counseling should be
in place to help children cope with life situation and its long-term effects.
 B. Exposure to Biologic Agents

Biologic Agents of Concern by Category

Category A Anthrax Bacillus anthracis
Smallpox Variola major
Tularemia Francisella tularenis
Plague Yersinia pestis
Viral hemorrhagic fevers Ebola, Marburg,
Lassa
Botulinum Clostridium botulinum toxi
Category B Q fever Coxiella burneti
Brucellosis Brucella species
Glanders Burkholderia mallei
Melioidosis Burkholderia pseudomallei
Viral encephalitis alphaviruses
Typhus Rickettsia prowazekit
Biotoxins ricin, staphylococcal enterotoxin B
Psittacosis Chlamydia psittaci
Food safety threats Salmonella
Water safety threats Vibrio cholerae
Category C Emerging threat agents Nipah and hantavirus
Multidrug-resistant tuberculosis
Tick-borne encephalitis
Tick-borne hemorrhagic fever virus
Yellow fever

Definitive Treatment
1. Anthrax
 Anthrax
 Cutaneous Anthrax
Signs and Symptoms
 Initial painless papulovesicular lesion surrounded by massive interstitial edema.
 Eschar develops within 2-5 days
 Systemic symptoms include fever, and leukocytosis
 Bacteremia may developed if delayed treatment.

Diagnosis

 Serum polymerase chain reaction and skin biopsy

 Systemic (inhalation) anthrax

Signs and Symptoms
 Fever
 Myalgia
 Fatigue
  Headache
 Malaise
 Nonproductive cough for 2-3 days, severe respiratory distress, cyanosis, chest pain,
diaphoresis, shock and death over 24-36 hours.

Treatment

 Hospitalization—monitor electrolyte and hematological status

 Administer intravenous antibiotics
 Initial treatment—Ciprofloxacin or doxycycline IV therapy
 Oral therapy—initiated once improvement is noted. One or two antimicrobial agents
including either ciprofloxacin or doxycycline for the first 7-10 days.
 Remaining days until 60 days—Amoxicillin is administered for the completion of the
remaining 60 days of therapy.
2. Botulism
 Usually tied to a common food source but if no identifiable food source or event, it may be a
case of intentional release of possible inhaled botulism toxin.
 Trivalent Equine botulinum antitoxin—prevent advancement of symptoms but does not reverse
the disease in children with symptoms.
 Botulism Immune Globulin Intravenous (human)—administered for infantile botulism.

C. Exposure to chemical agents

 Prehospital Treatment
1. Upon arrival at the scene of a chemical release, EMS, in conjunction with hazardous
materials teams, assess the situation and identify potentially exposed individuals.
2. Based on their findings, skin decontamination may be warranted. As in radiological
exposures, males and females are decontaminated separately, and young children
would stay with their mothers, while older children go through same-gender
decontamination.
3. In chemical exposures, EMS personnel will wear special protective equipment that
covers their entire bodies, and their faces may not be visible through their masks. The
EMS and hospital emergency responders in decontamination events can stay in
protective gear for limited periods of time before requiring rest, rehydration, and rehab,
increasing the need for manpower.
4. Young children may become frightened and uncooperative at the sight of such heavily
dressed, anonymous emergency care providers-_having their clothes cut from their
bodies and removed by strangers, then being cleansed with sufficient amounts of
warmed water to completely rinse the victims after removal of clothing. Solutions such
as 0.5% sodium hypochlorite (dilute bleach) should be avoided as they are known to
irritate the skin.
5. In addition, the use of soap increases the risk of injury associated with slips, falls, and
not being able to hold on to slippery infants or small children.
6. Additional safety measures may be required such as placing infants and very young
children in plastic laundry baskets or store carts to move them safely through a
decontamination station.
7. It should be anticipated that although adults may understand the given situation,
children are likely to become inconsolable and this will affect how quickly
decontamination can be performed. As in any situation where there is a predominance
of children, additional healthcare providers will be needed to assist children through the
decontamination process. Words of encouragement and praise ("You are doing a great
job") will be much appreciated.
8. As with adults decontamination is completed before the initiation of pediatric advanced
life support protocols. The decision to initiate decontamination is an important one and
the process requires specialty-trained personnel an adequate manpower.
9. Water is the preferred decontaminant and water-based decontamination should be
delivered at a low pressure (50-60 PSI), high volume, tepid temperature, and with a
duration of no longer 3 minutes to ensure thorough soaking.
 Treatment
1. For Malathione/ Sevin exposure
- pralidoxime chloride
-Diazepam—if convulsion occurs
- Atropine—for Sevin exposure

2. For Vesicant such as mustard or lewsite producing erythema, burning and vesication
followed by desquamation of skin:
-- wash skin with soap and water solution
---Adsorbent powder can be applied on skin to absorb mustard then remove with
moist cloth
--- Prepare intubation set and mechanical ventilator for children exposed to mustard
--- eye exposure requires copious flushing with water or normal saline. Thorough
eye examination should be made. Corneal lesions are treated with antibiotics and
mydriatic-cycloplegic medication; petroleum jelly applied to eyelids will prevent
them from adhering together.